DUBOIS, PA - State health inspectors identified significant infection control breaches during wound care and documented unsafe kitchen equipment conditions at Dubois Nursing Home during a May 15, 2025 inspection, raising concerns about basic safety protocols at the 212 South Eighth Street facility.
Critical Infection Control Breach During Wound Care
The most serious violation occurred when a licensed practical nurse failed to follow fundamental infection control procedures while treating a surgical wound on a resident's heel. The incident, observed directly by state inspectors on May 15 at 8:36 a.m., involved Licensed Practical Nurse 8 performing wound care on Resident 59 without changing gloves or sanitizing hands between removing contaminated dressings and applying clean wound materials.
According to the inspection report, the nurse donned a gown and gloves before using scissors to remove the existing dressing from the resident's right heel surgical wound. However, she then proceeded to cleanse the wound area with Vashe wound cleanser and gauze while still wearing the same gloves that had just handled the soiled dressing. The nurse continued wearing these potentially contaminated gloves while applying silver calcium alginate to the wound bed, covering it with an ABD pad, and wrapping the heel with kerlix gauze and tape.
When interviewed immediately after the observation, Licensed Practical Nurse 8 confirmed that she had not changed gloves or performed hand hygiene between removing the soiled dressing and performing the clean wound care procedure. The facility's Director of Nursing later acknowledged to inspectors that proper protocol required the nurse to "remove her gloves, sanitize her hands, and don new gloves after removing the old dressing and before placing the new one."
This violation directly contradicted the facility's own hand hygiene policy, which specifically stated that hands should be sanitized or washed before and after glove use. The policy, dated January 31, 2025, identified hand hygiene as an important infection control measure to prevent illness in skilled nursing homes.
Medical Significance of Cross-Contamination Risks
The failure to change gloves and perform hand hygiene between dirty and clean wound care procedures creates multiple serious health risks. When healthcare workers touch contaminated wound dressings and then immediately handle clean wound supplies with the same gloves, they can transfer bacteria directly into the open wound site. This cross-contamination significantly increases the risk of wound infections, which can be particularly dangerous for elderly nursing home residents.
Surgical wounds, like the heel wound being treated on Resident 59, are especially vulnerable to infection. The presence of silver calcium alginate in the treatment plan suggests the wound required antimicrobial protection, making proper sterile technique even more critical. Silver-infused dressings are typically used for wounds at higher risk of infection or those that have shown signs of bacterial colonization.
For elderly residents, wound infections can lead to serious complications including cellulitis, osteomyelitis (bone infection), sepsis, and delayed wound healing. These complications often result in extended hospital stays, additional surgeries, increased pain and discomfort, and in severe cases, can be life-threatening. The risk is particularly elevated in nursing home populations where residents often have compromised immune systems, diabetes, poor circulation, and other conditions that impair wound healing.
Standard wound care protocol requires healthcare workers to treat the removal of soiled dressings as a contaminated procedure and the application of new dressings as a clean or sterile procedure. The transition between these two phases must include proper hand hygiene and fresh gloves to maintain this critical barrier against infection. This basic infection control principle is taught in all nursing programs and is considered fundamental to safe patient care.
Unsafe Kitchen Equipment Conditions Persist Despite Cleaning Schedule
Inspectors also documented concerning conditions in the facility's kitchen, where they observed thick accumulations of black grease on and around four of the six stovetop burners during multiple visits. The heavy grease buildup was noted during observations on May 12 at 9:46 a.m., and again on May 13 at both 8:38 a.m. and 1:37 p.m. The affected burners were located adjacent to the grill area on the stovetop.
The facility's Dietary Manager confirmed to inspectors that there was indeed "a large accumulation of heavy grease" on the majority of the stovetop burners. She acknowledged that while the stovetop had been cleaned on April 1, 2025, the scheduled May 1 cleaning had not been completed, allowing grease to accumulate for over six weeks.
Review of the facility's documentation revealed a monthly cleaning schedule for the stovetop, outlined in their routine stovetop cleaning policy dated January 31, 2025. The policy stated that routine cleaning schedules would be followed to keep all equipment at optimal levels of functioning and cleanliness. However, the missed May cleaning demonstrated a breakdown in following these established protocols.
Fire Hazards and Food Safety Concerns
Excessive grease accumulation on cooking surfaces presents both immediate safety hazards and ongoing food safety risks. Grease buildup on stovetop burners significantly increases the risk of kitchen fires, as accumulated grease can ignite when exposed to high heat or open flames. Kitchen fires in healthcare facilities are particularly dangerous due to the presence of residents with limited mobility who cannot evacuate quickly.
Beyond fire risks, heavy grease deposits harbor bacteria and can contaminate food during preparation. Grease buildup also affects equipment performance, causing uneven heating that can result in improperly cooked food. In healthcare settings, where many residents have compromised immune systems, foodborne illnesses can have severe consequences.
The location of the affected burners next to the grill area suggests these were actively used cooking surfaces, not spare burners, making the extended period without cleaning particularly concerning. Professional kitchen standards require daily cleaning of cooking surfaces with deep cleaning performed weekly or bi-weekly, far exceeding the facility's monthly schedule even when properly followed.
Pattern of Basic Safety Protocol Failures
These violations reveal concerning gaps in the facility's adherence to basic safety protocols. Both the infection control breach and the kitchen maintenance failure involved situations where established policies existed but were not followed. The facility had appropriate written policies for hand hygiene and equipment cleaning, yet staff failed to implement these fundamental procedures.
The direct observation of improper wound care technique suggests this may not have been an isolated incident. When a nurse performs incorrect procedures while being observed by state inspectors, it raises questions about adherence to protocols during routine care when oversight is less intense. Similarly, the kitchen cleaning lapse that extended over six weeks indicates potential systemic issues with schedule compliance and supervision.
Regulatory Citations and Compliance Requirements
The inspection resulted in citations under multiple Pennsylvania regulatory codes. The infection control violation was cited under 28 Pa. Code 211.12(d)(1)(5) for Nursing Services, while the kitchen equipment issues fell under 28 Pa. Code 201.18(e)(6) for Management and 28 Pa. Code 211.6(c) for Dietary Services. Additional citations included 28 Pa. Code 201.14(a) for Responsibility of Licensee and 28 Pa. Code 201.18(e)(1) for Management.
The facility was also cited under federal regulation F880 for failing to provide and implement an effective infection prevention and control program, and F908 for failing to keep essential equipment working safely. These violations were classified as causing "minimal harm or potential for actual harm" and affected "few" residents according to the inspection report.
Implications for Resident Care and Facility Operations
These findings highlight the importance of consistent adherence to basic healthcare protocols in protecting vulnerable nursing home residents. While classified as minimal harm, both violations represent fundamental breakdowns in safety systems designed to protect residents from preventable infections and injuries. The facility must now develop and submit a plan of correction addressing how they will prevent similar violations in the future, including staff retraining, enhanced supervision, and improved compliance monitoring systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2025-05-15 including all violations, facility responses, and corrective action plans.
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